Medication Error Rate Exceeds 5% Due to Improper Administration and Crushing of Medications
Penalty
Summary
A medication error rate of 6.9% was identified during observation of medication administration by an LPN. The LPN dispensed an unknown amount of diclofenac sodium 1% gel for a resident's arthritis pain and inflammation, failing to use the manufacturer's enclosed dosing card as required. The LPN was unaware of the measuring device included in the medication packaging and could not confirm the correct dose, resulting in improper administration. The medication administration record (MAR) specified a two-gram dose, but the LPN guessed the amount and only discovered the dosing card after the error was pointed out. Additionally, the same LPN crushed and administered an extended-release medication, omeprazole 20mg delayed-release oral tablet, to another resident who required medications to be crushed. The MAR did not indicate that these medications should be crushed, and the LPN was unaware that omeprazole was a delayed-release formulation, only realizing the error after reviewing the medication label. The facility's policy and the manufacturer's recommendations both specify that extended-release or delayed-release medications should not be crushed and that medications must be administered as prescribed and in accordance with manufacturer specifications.